The association between menstrual hygiene, workplace sanitation practices and self-reported urogenital symptoms in a cross-sectional survey of women working in Mukono District, Uganda

Background Women worldwide experience challenges managing their periods. Menstrual and genital hygiene behaviours have been linked to negative health outcomes, including urogenital symptoms and confirmed infections. However, evidence testing this association has been limited and mixed. This study aimed to (1) describe the menstrual care practices and prevalence of self-reported urogenital symptoms among working women in Mukono District, Uganda, and (2) test the associations between menstrual and genital care practices, and urogenital symptoms. Methodology We undertook a cross-sectional survey of women aged 18–45 working in markets, schools, and healthcare facilities in Mukono District, with 499 participants who had menstruated in the past two months included in this analysis. We developed an aggregated measure of menstrual material cleanliness, incorporating material type and laundering practices. Associations with urogenital symptoms were tested using the aggregated material cleanliness measure alongside the frequency of changing materials, handwashing before menstrual tasks, and sanitation practices. Results Among our sample, 41% experienced urogenital symptoms in the past month. Compared to women exclusively using disposable pads, using appropriately cleaned or non-reused improvised materials (PR = 1.33, 95%CI 1.04–1.71), or inadequately cleaned materials (improvised or commercially produced reusable pads) (PR = 1.84, 95%CI 1.46–3.42) was associated with an increased prevalence of self-reported urogenital symptoms in the last month. There was no difference between those using disposable pads and those using clean reusable pads (PR = 0.98; 95%CI 0.66–1.57). Infrequent handwashing before changing materials (PR 1.18, 95%CI: 0.96–1.47), and delaying urination at work (PR = 1.37, 95%CI: 1.08–1.73) were associated with an increased prevalence of self-reported symptoms. Conclusion Prevalence of self-reported urogenital symptoms was associated with the type and cleanliness of menstrual material used as well as infrequent handwashing and urinary restriction. There is a need for interventions to enable women to maintain cleanliness of their menstrual materials and meet their menstruation, urination and hand washing needs at home and work.


Abstract:
Background Women worldwide experience challenges managing their periods. Menstrual and genital hygiene behaviours have been linked to negative health outcomes, including urogenital symptoms and confirmed infections. However, evidence testing this association has been limited and mixed. This study aimed to (1) describe the menstrual care practices and prevalence of self-reported urogenital symptoms among working women in Mukono District, Uganda,and (2) test the associations between menstrual and genital care practices, and urogenital symptoms. Methodology We undertook a cross-sectional survey of women aged 18-45 working in markets, schools, and healthcare facilities in Mukono District, with 499 participants who had menstruated in the past two months included in this analysis. We developed an aggregated measure of menstrual material cleanliness, incorporating material type and laundering practices. Associations with urogenital symptoms were tested using the aggregated material cleanliness measure alongside the frequency of changing materials, handwashing before menstrual tasks, and sanitation practices. Results Among our sample, 41% experienced urogenital symptoms in the past month. Compared to women exclusively using disposable pads, using appropriately cleaned or non-reused improvised materials (PR=1.33, 95%CI 1.04-1.71), or inadequately cleaned materials (improvised or commercially produced reusable pads) (PR=1.84, 95%CI 1.46-3.42) was associated with an increased prevalence of self-reported urogenital symptoms in the last month. There was no difference between those using disposable pads and those using clean reusable pads (PR=0.98; 95%CI 0.66-1.57). Infrequent handwashing before changing materials (PR 1.18, 95%CI: 0.96-1.47), and delaying urination at work (PR=1.37, 95%CI: 1.08-1.73) were associated with an increased prevalence of self-reported symptoms. Conclusion Prevalence of self-reported urogenital symptoms was associated with the type and cleanliness of menstrual material used as well as infrequent handwashing and urinary restriction. There is a need for interventions to enable women to maintain cleanliness of their menstrual materials and meet their menstruation, urination and hand washing needs at home and work. Participants who reported symptoms were referred to nearby public health facilities for further management.

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General guidance is provided below. Prevalence of self-reported urogenital symptoms was associated with the type and cleanliness of 57 menstrual material used as well as infrequent handwashing and urinary restriction. There is a need 58 for interventions to enable women to maintain cleanliness of their menstrual materials and meet 59 their menstruation, urination and hand washing needs at home and work. 60 61 62 63 64 Introduction 69 As defined in 2021, "Menstrual health is a state of complete physical, mental, and social well-being 70 and not merely the absence of disease or infirmity, in relation to the menstrual cycle" (1). Women, 71 girls, and people who menstruate worldwide experience challenges to their menstrual health, 72 resulting from inadequate access to clean menstrual materials, supportive infrastructure for 73 menstrual management, access to knowledge and support, and sociocultural environments which 74 frequently stigmatize menstruation (2). 75 Menstrual hygiene, the hygienic management of menstrual bleeding, represents one key 76 requirement for menstrual health, describing the use of sufficient, clean menstrual materials and 77 access to supportive facilities for washing the body and laundering materials (2-6). Menstrual 78 hygiene has been hypothesised as a risk factor for urogenital infections, including reproductive tract 79 infections (RTIs) and urinary tract infections (UTIs). Non-sexually transmitted RTIs with hypothesised 80 links to menstrual hygiene include bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC) (7). 81 BV and VVC can cause significant vaginal irritation, malodour, impact on sex life, self-esteem, and 82 mood disorders (8,9), and have been associated with an increased risk of HIV infection (10). BV has 83 also been associated with human papillomavirus infection (10) and adverse pregnancy outcomes 84 (10) including, premature rupture of membranes, preterm delivery, low birth weight, 85 chorioamnionitis, and spontaneous abortion (11). Menstrual hygiene has also been hypothesised to 86 be linked with UTIs. UTIs can cause significant discomfort, have a detrimental influence on quality of 87 life (12), and complications of UTI, like pyelonephritis, are associated with a significant burden of 88 care due to risk of hospitalisation (13). Moreover, a qualitative investigation of women's menstrual 89 experiences at work in Uganda found significant worries and discomfort related to urogenital 90 symptoms (14). 91 While menstrual hygiene practices have hypothesised links with urogenital infection, limited studies 92 have evaluated this relationship, and there have been mixed results (2,15,16). In a 2013 systematic 93 review (10), menstrual hygiene practices (including use of reusable or improvised absorbents like 94 cloth or toilet paper, or a low hygiene index score), were found to be associated with self-reported 95 vaginal discharge, or clinically-or laboratory-confirmed BV in seven cross-sectional studies (17-23). 96 However, there was significant variation in methodology and overall low quality (10). Meta-analysis 97 of a subset of studies found no association between clinically confirmed BV and menstrual hygiene 98 (10). Since this review, further cross-sectional studies have found that symptoms of or clinically-or 99 laboratory-confirmed RTIs or UTIs may be more likely in women with number of different menstrual 100 hygiene practices including type of material used, frequency of absorbent material changing, 101 washing and drying practices, handwashing, and availability of private sanitation facilities and soap 102 and/or water (24-29). A 2015 hospital-based case-control study in Odisha, India found increased 103 likelihood of symptoms or diagnosis of urogenital infection with "less adequate" menstrual 104 practices, including a lack of privacy for changing, cleaning and washing during menstruation (30). 105 Symptoms of and laboratory-confirmed UTIs and BV were also more likely in women using reusable 106 cloth compared to using disposable pads (30). A 2020 school-based interventional prospective 107 cohort study in Rwanda found no difference in rates of laboratory-confirmed UTI but a decreased 108 rate of vulvovaginal symptoms (bothersome discharge and/or odour) in users of menstrual pads 109 compared to no menstrual pads (31). A 2022 study nested within a pair-matched cohort study in 110 Odisha, India found that household latrines or bathing areas with access to piped water had a 111 moderate impact on adequate menstrual hygiene practices (adequate frequency of absorbent 112 change, washing the body with soap and privacy for managing menstruation) but no evidence of 113 effect of on self-reported urogenital infection symptoms (32). A recent 2022 systematic review (33) 114 found several menstrual hygiene practices that increased risk of laboratory-confirmed RTIs, including 115 increased risk of VVC with use of reusable materials, drying reusable pads inside the house and 116 storing them inside the toilet. Bathing with water alone showed an increased association with 117 symptoms of urogenital infection compared with washing with soap and water during menstruation. 118 Not drying the genital area or using cloth for drying it, and not handwashing, were associated with a 119 higher risk of genital infections. In summary, extant approaches to testing the association between 120 menstrual hygiene practices and urogenital infection and findings have been mixed. Many studies 121 have tested hygiene practices individually. Sanitation facility type as a variable denoting potential 122 exposure to fecal contamination of fomites within the environment (34) in which menstrual 123 materials are changed has not been specifically explored in the previous literature. Further, most 124 past research has drawn a dichotomy between disposable pads and other menstrual materials. 125 However, the availability and use of commercially produced reusable products is increasing. This 126 necessitates an updated consideration of menstrual materials and practices, including a meaningful 127 comparison of disposable and reusable materials. 128 Limited research has described adult women's menstrual practices, particularly in the workplace. As 129 the importance of menstrual health has gained increased recognition, most focus in research and 130 intervention has been for adolescents (35). Adult women's experiences and needs require further 131 exploration and understanding to be able to identify avenues for intervention (36). Understanding 132 the menstrual practices of women in workplaces, alongside challenges for urination, which may 133 increase risk of UTI (37), would allow a better understanding of potential causes of genital irritation 134 in working women and inform improved support for menstruation in the workplace. 135 The present study 136 This study aimed to describe the menstrual care practices of working women in Mukono District, 137 Uganda, to report the prevalence of self-reported urogenital symptoms among this population, and 138 to investigate the associations between menstrual care practices, urinary restriction, and the 139 prevalence of self-reported symptoms of urogenital infections (BV, VVC and UTI). 140 Extending on past research, this study aimed to disrupt the dichotomy of disposable pads compared 141 to other methods and compare commercially produced reusable pads and improvised reusable 142 materials, as well as compare clean and unclean reusable materials. We developed an aggregated 143 measure of material cleanliness based on past research as an exposure measure. In addition, we 144 investigated other key practices, including frequency of changing materials, handwashing before 145 menstrual tasks, and sanitation facility types and practices, like availability of water for genital 146 washing. Past qualitative research among the study population (14) found that almost all 147 participants believed it was essential to wash their genitals every time they changed their menstrual 148 materials, thus representing a key hygiene practice accompanying menstruation. According to the 2017 Performance Monitoring and Accountability survey (41), only 35% of women 160 in Uganda reported having everything they need to manage their menstruation. In the same survey, 161 most women reported using disposable pads (84% urban, 59% rural), followed by reusable cloths 162 (22% urban, 49% rural) as menstrual absorbent. 163 Household basic hygiene coverage (availability of a handwashing facility with soap and water at 164 home (42) All marketplaces in Mukono District that operated for at least three days a week for a minimum of 174 eight hours a day were identified with assistance from the local government and included (n=10). 175 Neighbouring government primary schools and public healthcare facilities were then sampled. For 176 each of the ten markets, five teachers and five healthcare facility workers were recruited. 177 In each market, 50% of the female worker population were sampled, except for the largest market in 178 the area, for which 20% of the market population was sampled to ensure adequate participant 179 representation from the smaller markets. Every second or fifth working woman was systematically 180 sampled by enumerators who mapped each market. Women aged 18-45 years, who had worked at 181 least three days per week over the last month at their relevant workplace were eligible (14), with 182 ineligible participants replaced by a neighbouring worker. Women who reported menstruating in the 183 past six months were asked questions related to menstruation. The larger quantitative study results 184 detailing participants' broader menstrual health needs at work and explorations of associations 185 between unmet needs and women's work and wellbeing are published elsewhere (38). In this study, 186 we used data from participants who reported menstruating in the last two months to align recent 187 menstrual hygiene practices with reports of urogenital symptoms in the past month. Questions captured practices at home and in the workplace and were used to describe women's 203 menstrual care and challenges at work, and to construct exposures. 204 Urogenital symptoms were measured by asking participants if they had experienced one or more 205 self-reported symptom of urogenital infections (burning or discomfort when urinating; itching or 206 burning in the genital region; unpleasant or fishy odour from genital area; or abnormal vaginal 207 discharge (unusual texture and colour: e.g., milky, white, grey, green, or yellow discharge)) in the last 208 month. 209 Data on covariates was collected using sociodemographic questions capturing participants' age, level 210 of educational attainment, and workplace type. A 5-item lived poverty index (48) asking how 211 frequently participants' households had gone without food, water, medical care, cooking fuel, or 212 cash income in the past year was used to calculate a poverty score of 0-20 for each participant, with 213 20 denoting the highest poverty score. 214

215
Menstrual hygiene practices investigated for their association with urogenital symptoms in past 216 studies were reviewed to inform the variables included and constructed for this study (10,(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33). A 217 full list of questions used in this study are presented in S1 Supplementary Materials Table 1. 218 219 We developed an aggregated measure of absorbent cleanliness, incorporating material type, along 220 with washing and drying practices. Commercially produced single-use (disposable) pads were 221 considered the cleanest material and reference group. Reusable menstrual pads that had been 222 appropriately cleaned were constructed as the next group. Reused materials were considered clean 223 if they were washed or soaked with soap or detergent and completely dry every time before use 224 during the last period. Improvised methods, including cloth/towel, underwear alone, cotton wool, 225 gauze (medical), and/or toilet paper, were then grouped. Those that were used only once (that is, 226

Menstrual absorbent cleanliness
where participants had reported that they did not wash and reuse any materials) or were cleaned 227 appropriately, were grouped as 'improvised materials clean or not reused'. Finally, any reused 228 materials (commercially produced or improvised) that were not cleaned appropriately were included 229 in the final grouping. Only six participants reported using reusable pads that were "not clean", and 230 thus this group was combined with improvised materials that were "not clean". When reporting the 231 type of menstrual material used, participants reported all the materials they had used during their 232 last period. Participant material was grouped according to the 'least clean' category of materials. 233 This variable construction allowed all menstrual material types to be included in the same final 234 model. 235

Washing and drying practices
236 Sub-group analysis assessing individual material cleaning practices only for those reusing materials 237 were included for comparison. In addition to washing with soap or detergent and drying completely, 238 additional cleaning methods were assessed; covering materials while drying, drying in the sun, and 239 ironing materials before reuse. 240

241
The location usually used to urinate, sanitation facility type usually used for urinating when at work 242 (pour flush toilet, ventilated improved pit latrine or composting toilet, pit latrine with a slab, 243 unimproved facility (pit latrine without a slab, bucket/pan, bushes/waterway, in the corridors, or 244 bathroom) or no facility, and never urinates at work), and whether water was available for washing 245 at that location was used, to capture the potential exposure to fecal contamination of surfaces that 246 may be touched prior to changing menstrual materials and to unclean water for genital washing 247 during menstruation. The qualitative portion of the study found that almost all participants believed 248 it was essential to wash their genitals every time they changed their menstrual materials (14). It was 249 therefore assumed that participants washed their genitals each time their menstrual materials were 250 changed. Questions about the place usually used for urination when at work and whether water for 251 washing was available and/or if participants brought their own water for cleansing were used as a 252 proxy for location and water used for washing when changing menstrual materials. 253  Table 1. 294 Menstrual care at home and at work 298 Participants used varying combinations of materials to manage their periods at home and at work 299 (Table 2), with the majority (n=319, 64%) using disposable pads exclusively. A detailed breakdown of 300 the menstrual materials used is presented in S1 Supplementary Materials Table 2 with a breakdown 301 of material cleanliness in S1 Supplementary Materials Table 3. 302 A total of 45 (9%) participants reported using a commercially produced reusable product. Of these, 303 thirty-nine used only reusable pads (n=25) or these products combined with disposable pads (n=13) 304 or with an improvised method (n=1) and cleaned them appropriately. Six participants used 305 designated reusable pad products that were unclean, these were categorised as 'reused methods 306 not clean in the same category as unclean reused improvised materials. 307 A total of 136 (27%) participants used an improvised menstrual material. Most cleaned these 308 appropriately, while twenty-two participants reused unclean improvised materials. 309

Menstrual hygiene practices
The locations that materials were most often changed and disposed of at home and at work are 310 detailed in Table 2. Sixty-five percent of participants (n=324) were always able to change their 311 materials when they wanted to, and the majority (n=252, 51%) changed their materials three times a 312 day on the heaviest day of their last menstrual period. Less than half (n=202, 41%) washed their 313 hands every time before changing their materials. Eleven percent (n=57) usually went home to 314 urinate when at work, 53% (n=263) used a sanitation facility that had water for washing available, 315 27% (n=136) used a sanitation facility, bucket/pan or bushes/waterway and brought their own water 316 for cleansing, and 8% (n=41) used a sanitation facility, bucket/pan or bushes/waterway and did not 317 have water available for washing nor bring their own water for cleansing. The majority (86%, n=431) 318 usually used an improved facility to urinate at work, 8% (n=38) usually used an unimproved facility, 319 4% (n=20) used no facility, and 2% (n=10) went home to urinate when at work or never needed to 320 urinate at work. 321 Twenty-eight percent of participants (n=141) washed and reused menstrual materials. Of these, the 322 vast majority (n=132, 94%) used soap or detergent to soak or wash their materials every time, 24% 323 (n=34) ironed their materials before using them, and 12% (n=17) dried their materials in the sun 324 every time. For the majority (n=119, 84%), their materials were completely dry every time before 325 using them, and just over half (n=73, 52%) did not cover their materials with anything while drying 326 them. 327 Self-reported urogenital symptoms experienced by participants 328 Forty-one percent (n=206) of participants self-reported experiencing one or more urogenital 329 symptom (burning or discomfort when urinating; itching or burning in the genital region; unpleasant 330 or fishy odour from genital area; or abnormal vaginal discharge) in the last month, and 66% (n=100) 331 discussed their symptoms with a healthcare provider when they occurred. No consistent evidence of 332 patterns among symptom types experienced by participants in the last month emerged (displayed in 333 S1 Supplementary Materials Table 4). 334 335 336  (7) Bush/buried or bin/bucket outside sanitation place 2 (8) Able to change menstrual materials when wanted to at home and at work Always at home & always at work (or did not need to change during workday or did not attend work during period) 64.9 (324) Sometimes or never at home and/or work 35.1 (175) How many times menstrual materials were changed on the heaviest day of last menstrual period 1-2 times 31.3 (156) 3 times 50.6 (252) 4 or more times 18.1 (90) How often participants wash their hands before changing menstrual materials during last period Washed hands every time before changing materials during last period 40.6 (202) Washed hands sometimes or never before changing materials during last period 59.4 (296)

The place usually used to urinate when at work and whether water for washing is available at the location and/or if participants bring own water for cleansing
When at work usually goes home to urinate 11.4 (57) When at work usually urinates at a sanitation facility with water for washing available 52.7 (263) When at work usually urinates at a sanitation facility or in a bucket/pan or bushes/waterway and brings own water for cleansing 27.3 (136) When at work usually urinates at a sanitation facility or in a bucket/pan or bushes/waterway with no water for washing available and does not bring own water for cleansing 8.2 (41) Type of sanitation facility usually used to urinate when at work Pour flush toilet 38.3 (191) Ventilated improved pit latrine or composting toilet 21.6 (108) Pit with slab 26.5 (132) Unimproved or no facility 11.6 (58) Never urinates at work 2.0 (10) Washed and reused any menstrual materials during last period Washed and reused any menstrual materials during last period 28.3 (141) Did not wash and reuse any menstrual materials during last period 71.7 (358) Used soap or detergent to soak or wash menstrual materials during last period Used soap or detergent to soak or wash materials during last period every time 93.6 (132) Used soap or detergent to soak or wash materials during last period sometimes or never 6.4 (9) Ironed menstrual materials before reusing them during last period Ironed materials before using them during last period 24.1 (34) Dried materials in sun during last period sometimes or never 75.9 (107) Dried materials in the sun during last period Dried materials in sun during last period every time 12.1 (17) Dried materials in sun during last period sometimes or never 87.9 (124) Menstrual materials were completely dry before using them during last period Materials were completely dry every time before using them during last period 84.4 (119) Materials were completely dry sometimes or never before using them during last period 15.6 (22) Menstrual materials you covered with anything when drying Materials were not covered while drying during last period 52.1 (73) Materials were covered while drying during last period 47.9 (67) Associations between menstrual hygiene and urinary restriction and 342 urogenital symptoms 343 Associations between menstrual hygiene, urinary restriction, and experiencing one or more 344 urogenital symptom(s) in the last month are displayed in Table 3. Sub-group analysis for participants 345 reusing materials, reporting individual cleaning practices used, and additional cleaning including 346 drying materials in the sun, uncovered, or using an iron on materials, and their binary associations 347 with urogenital symptoms are displayed in Table 4. 348

Materials used
349 There was no difference in the prevalence of self-reported urogenital symptoms in the last month 350 between participants who used disposable pads only and participants who used reusable pads that 351 were clean or not reused (used with or without disposable pads) (aPR=0.98, 95% CI: 0.63 -1.59; 352 PR=0.98, 95% CI: 0.66-1.57) during their last period. The prevalence of self-reported urogenital 353 symptoms in the last month was 1.33 times higher (95% CI: 1.04 -1.71; PR=1.51, 95% CI: 1.20-1.90) 354 among participants who used improvised materials that were clean or not reused (used with or 355 without disposable pads and/or reusable pads), and 1.84 times higher (95% CI: 1.46 -3.42; PR=2.26, 356 95% CI:1.77-2.89) among participants who used reused, unclean materials (improvised materials 357 (n=22) or reusable pads (n=6)), than in participants who used disposable pads only during their last 358 period. In the sub-analysis of participants who washed and reused materials (n=141) (Table 4), the 359 prevalence of self-reported urogenital symptoms in the last month was 1.40 times (95% CI: 1.13-360 1.71) higher in participants who washed and reused menstrual materials than in participants who 361 did not reuse any during their last period. The prevalence of self-reported urogenital symptoms in 362 the last month was 1.31 times higher (95% CI 0.81-2.15) in participants who did not use soap or 363 detergent to soak or wash their materials every time, 1.13 times higher (95% CI 0.76-1.69) in 364 participants who did not iron their materials before using them, 1.53 times higher (95% CI 0.78-2.98) 365 in participants who did not dry their materials in the sun every time, 1.77 times higher (95% CI 1.34-366 2.34) in participants whose materials were not completely dry every time before use, and 1.06 times 367 higher (95% CI 0.77-1.46) in participants whose materials were covered while drying during their last 368 period. 369

370
The prevalence of self-reported urogenital symptoms in the last month was 1.11 times higher (95% 371 CI 0.89-1.37) among participants who were not always able to change their menstrual materials 372 when they wanted to (or did not need to change during workday or did not attend work during their 373 last period) than in participants who were always able to change their materials when they wanted 374 to. The prevalence of self-reported urogenital symptoms increased along with the number of times 375 menstrual materials were changed (Table 3). However, these findings were not statistically 376 significant. 377

378
The prevalence of self-reported urogenital symptoms in the last month was 1.18 times higher (95% 379 CI: 0.96 -1.47; PR=1.23, 95% CI:0.99-1.54) among participants who did not wash their hands every 380 time before changing their materials than among participants who washed their hands every time 381 before changing their materials during their last period. The location used for urination, sanitation 382 facility type classification used for urination at work (pour flush toilet, ventilated improved pit latrine 383 or composting toilet, pit latrine with a slab, unimproved facility (pit latrine without a slab, 384 bucket/pan, bushes/waterway, in the corridors, or bathroom) or no facility, or never urinates at 385 work), and water availability for genital washing were not significantly associated with self-reported 386 urogenital symptoms. 387

388
The prevalence of self-reported burning or discomfort when urinating was 1.59 times higher (95% CI: 389 1.12 -2.26) and the prevalence of any self-reported urogenital symptom in the last month was 1.37 390 times higher (95% CI: 1.08-1.73; PR=1.49, 05% CI:1.17 -1.89) among participants who sometimes or 391 always needed to delay urinating at work than among participants who never needed to delay 392 urinating at work in the last month. 393 394  Materials used, handwashing, and urinary restriction 1 Multivariable Poisson regression analysis adjusting for age, poverty score, workplace type, and 2 highest level of education attainment (presented as an adjusted prevalence ratio (aPR) in Table 3) 3 looked at associations between self-reported urogenital symptoms and materials used, frequency of 4 handwashing prior to changing materials, and urinary restrictions at work. Analysis showed that 5 compared to using disposable pads only, using clean or not reused improvised materials (with or 6 without disposable and/or reusable pads) (PR=1.51, 95% CI: 1.20 -1.90; aPR=1.33, 95% CI: 1.04 -7 1.71), or unclean reused materials (either reusable pads or improvised materials, with or without 8 disposable pads) (PR=2.26, 95% CI: 1.77 -2.89; aPR=1.84, 95% CI: 1.46-3.42) was associated with an 9 increased prevalence of self-reported urogenital symptoms in the last month among participants. 10 Compared to always washing their hands before changing materials, participants who sometimes or 11 never washed their hands before during their last menstrual period (PR=1.23, 95% CI: 0.99 -1.54; 12 aPR=1.18, 95% CI: 0.96-1.47) had an increased prevalence of self-reported urogenital symptoms in 13 the last month. Compared to participants who never needed to delay urination at work, participants 14 who sometimes or always needed to delay urination at work in the last month (PR=1.49, 95% CI: 15 prevalence of self-reported urogenital symptoms, and the associations between menstrual hygiene 24 practices and urogenital symptoms. Forty-one percent of participants self-reported experiencing one 25 or more urogenital symptom within the past two months. 26 The menstrual hygiene practices that were significantly associated with urogenital symptoms after 27 adjustment for age, poverty score, workplace type, and education, included menstrual absorbent 28 cleanliness, handwashing prior to changing materials, and urinary restriction. Using improvised 29 materials that were cleaned appropriately or not reused was associated with a 33% greater 30 prevalence of symptoms. A hypothesis for this finding is that even if not reused, improvised 31 materials may not be adequately clean on initial use. Irritation from improvised methods may also 32 occur due to chaffing as they are not held in place as easily and are not designed for the purpose of 33 prolonged skin contact. Previous qualitative studies have found reports of irritation and chafing with 34 improvised materials like cloth (50, 51). Use of inadequately cleaned reusable materials, that is 35 materials that were not washed/soaked with soap/detergent or completely dried, was associated 36 with an 84% greater likelihood of reporting urogenital symptoms. While this represented a small 37 proportion of the sample (6%), this population of women bears a significant burden of discomfort 38 with 79% reporting at least one urogenital symptom. 39 Most women using reusable menstrual pads appropriately cleaned them, and there was no 40 difference in symptom prevalence among participants using disposable compared to clean reusable 41 pads. This finding contrasts with previous research which has found urogenital infections were more 42 common in women using reusable materials compared to disposable pads (10, 17-23, 30, 33), but 43 did not differentiate between improvised reusables and reusable pads. These findings are 44 particularly important in the context of increasing uptake of commercially produced reusable 45 menstrual pads as a cost-and environmentally sustainable alternative to disposable pads. Our 46 results suggest that, in this study setting, women taking up reusable clean pads experience the same 47 benefits of lower prevalence of urogenital symptoms as those using disposables. 48 Needing to delay urination at work was associated with a significantly greater prevalence of 49 symptoms, particularly burning or discomfort when urinating, a symptom of UTI, which is in line with 50 evidence supporting delayed urination as a risk factor for UTI (37). Inconsistent handwashing prior to 51 changing menstrual materials showed an association with symptoms in binary and multivariable 52 models, although falling short of statistically significant thresholds. Previous cross-sectional studies 53 have found an association between inadequate or lack of facilities available for handwashing and 54 diagnosed genital infection or urogenital symptoms (27,28,52). Along with providing adequate 55 facilities for urination, handwashing stations that can be used prior to changing menstrual materials 56 may help support genital health. 57 The prevalence of self-reported symptoms increased with an increased frequency of changing 58 menstrual materials; however, this was not a statistically significant finding. It is plausible that 59 women using poorer quality absorbents need to change them more often. Conversely, past research 60 has found that women diagnosed with BV reported a lower frequency of material changing (24, 30). 61

62
An in-depth qualitative study to investigate women's menstrual experiences at work in Uganda (14)  63 and previous research were used to inform development (38) and selection of survey questions for 64 this analysis. Building on past research, this study took a novel approach to assessing associations 65 between menstrual hygiene materials and urogenital symptoms, allowing for meaningful 66 comparison between reusable and disposable materials as well as clean and unclean reusable 67 materials. 68 Even though we were unable to take a full count of the workers and randomly sample them, a 69 feasible yet rigorous approach of proportional systematic sampling in the marketplaces was 70 undertaken (38). Due to practical limitations, only a small number of teachers and healthcare facility 71 workers were included. Multivariable comparisons included adjustment for workplace type, poverty, 72 and education level, however, results mostly describe the experiences and associations between 73 practices and urogenital symptoms among women working in markets. 74 Participants were not asked about sexual practices to determine risk of sexually transmitted 75 infections (STIs). STIs may have increased the likelihood of urogenital symptoms. There is likely to be 76 a symptom overlap with STIs and non-sexually transmitted urogenital infections, and sexual 77 intercourse may increase the risk of BV, VVC, and UTI. Women exposed (via skin contact) to water 78 contaminated with the cercariae of schistosomes (also known as "bilharzia") may have experienced 79 urogenital symptoms due to female genital schistosomiasis (FGS), instead of irritation related to 80 menstrual management. This study did not find an association between urination location and 81 genital wash water availability, and urogenital symptoms. However, participants were also not asked 82 about prior exposures to bilharzia-infested waters or about cleanliness of the genital wash water and 83 whether they used soap to wash their genitals. Information about whether water was available 84 (either present at the sanitation facility used for urination, brought by the participant, or neither) 85 when changing menstrual materials, with the assumption made that this was used for genital 86 washing, was included as potential exposure FGS during menstruation. FGS is prevalent in Uganda. 87 The national prevalence of schistosomiasis in females in Uganda in 2016-17 was 24% (53). FGS 88 occurs in approximately half (33 to 75%) of females with schistosomiasis infection (54) and is one of 89 the most common gynaecologic conditions in Africa (55). Symptoms of FGS include vaginal discharge 90 and genital itching or burning sensation (56), which, overlap with symptoms of BV, VVC, and UTI. 91 Prevalence of self-reported urogenital symptoms could have been due to STIs or FGS, and not 92 menstruation or urinary management practices. 93 Answers to questions about menstrual and urinary management and urogenital symptoms are 94 subject to recall and social desirability bias, particularly if participants were embarrassed to report 95 menstrual care. While the results from this study encouragingly did not find a difference in 121 outcomes when comparing disposable to clean reusable pads, further research comparing products, 122 and providing information about risk factors for urogenital infections is required. Reliable access to 123 soap and clean water and private spaces to adequately clean and dry reusable materials is required 124 to support menstrual health. Finally, accessible, clean, and affordable sanitation infrastructure is 125 essential to ensure women can urinate as needed in the workplace and further prevent the burden 126 of urogenital infections. 127 128